Treatment of Primary Hyperparathyroidism (PHPT) Symptoms
Surgical excision of the abnormally functioning parathyroid tissue is the definitive treatment for primary hyperparathyroidism and is typically indicated even when asymptomatic, given the potential negative effects of long-term hypercalcemia. 1
Surgical Management
Indications for Surgery
- Parathyroidectomy is the only definitive cure for PHPT and is recommended for patients with severe hyperparathyroidism. 2
- Surgery should be considered in all patients with PHPT, including those who are asymptomatic, due to the long-term risks of persistent hypercalcemia. 1
- Symptomatic patients presenting with bone demineralization, fractures, nephrolithiasis, nephrocalcinosis, muscle weakness, or neurocognitive disorders require surgical intervention. 1
Surgical Approaches
Two accepted curative operative strategies exist:
- Minimally Invasive Parathyroidectomy (MIP): A unilateral operation with limited dissection for targeted removal of a single adenoma, offering shorter operating times, faster recovery, and decreased perioperative costs. 1
- Bilateral Neck Exploration (BNE): Required when imaging is discordant or nonlocalizing, or when there is high suspicion for multigland disease (MGD). 1
MIP requires confident preoperative localization of a single parathyroid adenoma and uses intraoperative PTH monitoring to confirm removal of the hyperfunctioning gland. 1
Medical Management (Non-Surgical Candidates)
When Medical Management is Appropriate
Medical therapy is reserved for patients who cannot or do not want to undergo surgery, or for those unable to undergo parathyroidectomy. 3, 4
Pharmacological Options
For Hypercalcemia Control:
- Cinacalcet is the treatment of choice for controlling hypercalcemia in PHPT patients who cannot undergo parathyroidectomy. 2, 3, 4
- Cinacalcet reduces serum calcium to normal in many cases but has only modest effects on serum PTH levels and does not improve bone mineral density (BMD). 4
- Starting dose: 30 mg twice daily, titrated every 2-4 weeks through sequential doses up to 90 mg 3-4 times daily as necessary to normalize serum calcium. 3
For Bone Mineral Density Improvement:
- Bisphosphonate therapy (specifically alendronate) is recommended to improve BMD at the lumbar spine without altering serum calcium concentration. 2, 4
- Bisphosphonates do not address hypercalcemia but effectively increase bone density. 4
Combination Therapy:
- Using both cinacalcet and bisphosphonates together is reasonable to address both hypercalcemia and low BMD, though strong evidence for this approach is limited. 4
Calcium and Vitamin D Management
Calcium Intake:
- Do not restrict calcium intake in PHPT patients who do not undergo surgery; follow general population guidelines. 4
- Adequate calcium intake is important and should not be limited. 4
Vitamin D Supplementation:
- Patients with low serum 25-hydroxyvitamin D should be repleted to achieve levels ≥50 nmol/L (20 ng/mL) at minimum, with a goal of ≥75 nmol/L (30 ng/mL) being reasonable. 2, 4
- Vitamin D deficiency must be corrected as it can complicate PTH interpretation and worsen the clinical picture. 2
Post-Parathyroidectomy Management
Critical Monitoring:
- Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery to prevent hypocalcemia. 2
- Initiate calcium gluconate infusion if ionized calcium falls below normal. 2
- Provide calcium carbonate and calcitriol when oral intake is possible. 2
Common Pitfalls to Avoid
- Do not use cinacalcet in patients with CKD who are not on dialysis due to increased risk of hypocalcemia. 3
- Failing to assess vitamin D status before initiating treatment can complicate PTH interpretation and management decisions. 2
- Do not restrict calcium intake in PHPT patients, as this is counterproductive and not evidence-based. 4
- Imaging studies (ultrasound, sestamibi scan) are useful for surgical localization but have no utility in confirming or excluding the diagnosis of PHPT, which is purely biochemical. 1